The Princess Alexandra Hospital

Updated 16 June 2023

The Princess Alexandra Hospital NHS Trust provides acute and specialist services. The main site is the Princess Alexandra Hospital (PAH), which is a district general hospital. The trust has 2 satellite sites Herts and Essex Hospital and St Margaret’s Hospital.

The trust has 418 acute inpatient beds, 10 critical care beds and 46 maternity beds. They currently employ a total of 2,147 staff, of these 1,265 are nursing and midwifery and 557 are medical across the trust.

The total number of inpatient admissions for PAH from March 2021 to February 2022 totalled 57,349. From March 2021 to February 2022 there were a total of 28,031 A&E attendances, of which 7,128 were children. Of all A&E attendees 18.4% arrived by ambulance.

The PAH was built in the mid 1960’s, and the building is showing signs of age and there is very little room for expansion on the current site. The trust is part of the nationally led New Hospitals programme and the Government announced it is to receive funding to rebuild a new hospital in Harlow.

We carried out this short notice announced focused inspection of the emergency department (ED) at PAH on 29 March 2023.

The service was rated as inadequate following our previous inspection, published in November 2021. Following the last inspection, we issued an urgent notice of decision under Section 31 of the Health and Social Care Act 2008, to impose conditions on the trusts in respect of the regulated activity Treatment of disease, disorder or injury related to the core service of Urgent and Emergency Care services. We carried out this inspection to determine if improvement had been made against the conditions imposed.

The following conditions imposed in 2021 were:

The Registered Provider must ensure there are sufficient numbers of suitably qualified, skilled, competent and experienced nursing staff at all times to meet the needs of patients within all areas of the Emergency Department at the Princess Alexandra Hospital

The Registered Provider must operate an effective system which will ensure that every patient attending the Emergency Department at the Princess Alexandra Hospital has an initial assessment of their condition to enable staff to identify the most clinically urgent patients and to ensure they are triaged, assessed and appropriately streamlined

The Registered Provider must devise a process and undertake a review of current and future patients clinical risk assessments, care planning and physiological observations, and ensure that the level of patients’ needs are individualised, recorded and acted upon. This must include, but not limited to skin integrity, falls, and mental health assessments

The registered provider must ensure that it implements an effective system with the aim of ensuring all patients who present to the emergency department at the Princess Alexandra Hospital patient observations are completed within 15 minutes of arrival and as appropriately thereafter in line with trust policy.

We inspected the urgent and emergency care at PAH. This was a focused inspection and therefore we looked at the key questions safe, responsive, effective and well-led. We carried out this inspection to determine if improvement had been made against the conditions imposed in 2021.

Our rating of this location improved. We rated it as requires improvement because:

• The service did not always have enough staff to care for patients in all areas to keep them safe.
  
• Staff did not always complete risk assessments for each patient in a timely manner.
  
• Staff did not always keep contemporaneous care records.
  
• People could not always access the services when they needed them and waiting times for treatment was consistently worse than the national average.
  
• Patient follow up observations were not always completed in line with trust policy.
  
• Pain relief was not always offered in a timely way.
  
• Leaders did not always provide effective risk mitigation.
  
• The service’s governance processes did not always ensure effective patient flow and risk mitigation.
  
• The service did not have a robust streaming system to match patients to the most appropriate service.
• Call bells were not always in reach of patients.

However:

• The service had made improvements since our previous inspection ensuring that those with mental health conditions received appropriate care and treatment.
  
• The service had implemented a nationally recognised triage tool.
  
• All patients received an initial set of observations in line with trust policy.
  
• The service made sure staff were competent for their roles.
  
• The service was inclusive and considered individual needs and preferences.

We inspected the emergency department (ED) including minors area, majors area, the further assessment unit, resuscitation area (resus), rapid assessment and triage (RAT) area and paediatric emergency department.

We spoke with 25 members of staff including service leaders, nurses, doctors and healthcare assistants and 6 service users.

We observed care and looked at care records. We also looked at a wide range of documents including policies, standard operating procedures, meeting minutes, action plans, risk assessments and audit results.

Updated 17 November 2021

Updated 31 July 2019

Our rating of this service improved. We rated it as good because:

• The service had enough staff to care for patients and keep them safe. Staff received training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• Although staff understood how to protect patients from abuse, not all staff had received safeguarding training in line with national guidance.
• A nurse trained in advanced paediatric life support (APLS) or European paediatric advanced life support (EPALS) was not available on every shift. This was not in line with standards set by the Royal College of Nursing.
• Access to allied health professionals was limited, particularly on the Neonatal Intensive Care Unit.
• Discharge summaries were not consistently sent to GPs within 72 hours of discharge.
• Transition arrangements had improved since our last inspection but there was still more work to be done. Transitional pathways for children with epilepsy and children with complex allergies were under development.
• There was currently no formal strategy specifically for the service. Service leads had a plan to develop a strategy with involvement from staff, patients, and key groups representing the local community.

Updated 21 March 2018

Our rating of this service improved. We rated it as good.

Updated 31 July 2019

Our rating of this service stayed the same. We rated it as good because:

• All nursing staff in the end of life care team had completed their mandatory training.
• The maintenance and use of equipment kept patients safe, syringe drivers were maintained and used appropriately.
• Records were well maintained and kept securely.
• There were systems and processes in place to report incidents and staff told us they were encouraged to do so.
• Patient’s needs were assessed, and care and treatment delivered in line with evidence-based guidance to achieve effective outcomes.
• Pain was assessed and managed and there were assessment processes in place for patients who have difficulty communicating.
• The service ensured that staff had the skills, knowledge, and experience to deliver effective care, support, and treatment.
• The service ensured that patients were treated with kindness, respect, and compassion, and that they were given emotional support when needed.
• Patients were supported to be actively involved in making decisions about their care.
• Patients at the end of life were generally nursed in side rooms and there were facilities available for relatives to stay overnight.
• The special palliative care team would generally visit the patient on the day of referral.
• Leaders were visible and approachable. They had the skills needed and understood the challenges to quality and sustainability for end of life care services.
• Staff felt positive and proud of the quality of end of life care delivered and there was a strong culture of quality end of life care throughout that included both specialist and generalist staff.
• Risk registers included identified risks in relation to end of life care and these were regularly reviewed and actioned.

Updated 17 November 2021

Updated 19 October 2016

Outpatient and diagnostic imaging services at The Princess Alexandra Hospital have been rated as good overall. Safe, caring and well-led have been rated as good with responsiveness requiring improvement. We do not rate effective in outpatient and diagnostic services due to there being an inconsistent data set for services of these types.

During this inspection we followed up on a number of areas which we found to be inadequate or requiring improvement during our last inspection in July 2015. The previous issues related mainly to patients having to wait unsafe amounts of time before being offered an appointment. We found that the service had taken action and improvements were seen.

We rated this service as good because:

Staff were aware of how to report incidents and when this should be done. There was a clear escalation pathway for safeguarding concerns and medication was stored appropriately, in line with manufacturer’s guidance. Mandatory training compliance was good and staff were competent in their roles. However, the main outpatient department was dated and in need of repair and refurbishment, and 10 out of the 11 patient records we reviewed did not contain up to date patient information.

Policies and procedures were developed using relevant national best practice guidance and patient outcomes were monitored via national audit arrangements. However, the local audit plan was limited in content meaning that there was limited opportunity to improve patient outcomes locally.

Staff provided compassionate and respectful care to patients. We observed that staff were understanding and maintained patient dignity. The majority of patient feedback that we received during our inspection was positive, and the latest Friends and Family Test (FFT) results demonstrated 96% of patients would recommend the service.

Outpatient and diagnostic imaging services were well-led. There was a cohesive leadership team and staff felt managers were approachable and that there was a strong open culture. Patients and staff were engaged in the running of the service and staff were enabled to be innovative. Since our previous inspection, governance systems had been reviewed and a clear structure had been put in place.

Updated 31 July 2019

Our rating of this service improved. We rated it as good because:

• Mandatory training for nursing staff had improved significantly since our last inspection and mostly met the 90% target. Medical staff mandatory training had also improved to 60% with an action plan to improve to 90% by July 2019.
• Staff understood how to protect patients from abuse and safeguarding training had also improved with the addition of level three safeguarding for children.
• Staff collected safety monitoring information and shared results with staff, patients and visitors.
• The service generally controlled infection risk well and used control measures to prevent the spread of infection.
• The service made sure patients received the right medication at the right dose at the right time including assessing for pain relief.
• The service provided care and treatment that was planned and delivered in line with current evidence-based guidance. Managers monitored the effectiveness of care and treatment and used the findings to improve them.
• Staff gave patients enough food and drink to meet their needs and improve their health.
• Managers ensured staff were competent for their roles appraised staff’s work performance and held supervision meetings with them to provide support.
• Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion and dignity and provided emotional support to patients to minimise their distress.
• Staff involved patients and those close to them in decisions about their care and treatment.
• The service planned and provided services in a way that mostly met the needs of local people.
• The service took account of patients’ individual needs and developed services to meet them.
• The service treated concerns and complaints seriously, learned from them and shared these with staff.
• Service leads had the skills and abilities to run the service providing high-quality sustainable care.
• Managers across the service promoted a positive culture that supported and valued staff.
• The service used a systematic approach to quality improvement creating an environment in which generally reflected best practice. Governance structures, processes and systems of accountability were clearly set out.
• The service collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards.
• The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services and collaborated with partner organisations effectively.
• The service was committed to improving services by learning from when things went well or wrong, promoting training, research and innovation.

However:

• The service did not take timely action to protect patients from harm following recognition of patient risk, and we were not assured that duty of candour was always applied when things went wrong.
• Staffing remained a concern with significant vacancies both within the nursing teams and some medical staff teams.
• There was a lack of oversight in ensuring that deteriorating patients received the appropriate level of observations according to trust policy.
• Staff but did not always consent patients for surgery in line with best practice.
• There was a lack of oversight in ensuring that all out of date policies were reviewed and available for staff to use for example the fasting policy had been under review since 2014.
• People could not always access the service when they needed it. Waiting times from referral to treatment were not always in line with good practice or the England average.
• The service had systems to identify risks and risk management processes to eliminate or reduce them, but we were not assured that actions were always taken in a timely way.

Updated 16 June 2023